My patient, Megan, is 27. She has never had children and is certain she never wants them. In the days after the U.S. Supreme Court overturned Roe v. Wade, she scheduled surgery to have her fallopian tubes removed.
She was not alone. Tanesha, 29, a mother of two, decided her family was complete. And Cara, 30, already balancing care for a child, a sister’s children, and her aging mother, wanted to be sure she wouldn’t face another pregnancy. All three women sat across from me on a single afternoon, asking for the same procedure: permanent contraception, often referred to as “getting your tubes tied.”
At face value, none of these stories is surprising — I’m an OB/GYN and regularly perform the surgery for sterilization for women, which we call permanent tubal contraception. But it was odd that all three patients were squeezed into a single afternoon session. Usually, I might see one of these requests a week. Something had changed.
On June 24, 2022, the U.S. Supreme Court erased the nationwide right to abortion in its Dobbs decision. Many states immediately enacted bans. Pennsylvania, where I practice, did not. Yet fears of abortion bans traveled across state lines. The prospect of an unintended pregnancy now carried new weight: What if abortion became unavailable tomorrow?
Abortion is safe, essential health care. But growing evidence shows erosion of abortion access reverberates across every corner of reproductive medicine.
Sterilization is an effective and popular form of permanent contraception. For women, it involves removing or closing the fallopian tubes through abdominal surgery under general anesthesia — a riskier and less effective procedure than vasectomy, the equivalent for men. Despite that, women in the U.S. undergo sterilization at nearly three times the rate men do.
The burden of contraception has always fallen disproportionately on women, and tubal sterilizations remain more common in Black and Hispanic females and in those with lower income, less education, and who have had more children.
Unfortunately, sterilization often isn’t easy to get, especially for publicly insured women and for patients like Megan, who is younger and hasn’t had any children. Many OB/GYNs are taught that for patients like Megan, the risk of regret is high. But for women under 30, there is only a 1 percent increase in odds of experiencing regret.
Beyond provider misperceptions about age, there are other barriers. Public insurance for lower income patients requires a 30-day waiting period between signing consent and undergoing the procedure, a policy born out of the country’s shameful history of forced sterilizations. While meant to protect patients, this rule often functions as a barrier, leaving women without access to the contraception they choose.
Moreover, many requests for sterilization at the time of childbirth go unfulfilled, leaving postpartum mothers to coordinate their care amidst the chaos inherent in caring for an infant. Often, even when desired, abdominal surgery doesn’t rise to the top of the priority list and if insurance lapses, so does the opportunity for permanent contraception. Catholic hospital systems often prohibit the procedure altogether. For these reasons, as many as 50 percent of females who intend to have permanent contraception surgeries after the birth of their child do not follow through. And of those who are unable to be sterilized, about half will become pregnant again within the year after their last birth.
More women will want sterilization as abortion rules tighten
Now abortion bans are layered onto these longstanding issues. In my recent research, I examined sterilization trends in Pennsylvania, where abortion remains legal. We found a clear rise in permanent contraception after Dobbs — particularly among more educated, higher-income women and those who live further from abortion care, suggesting that for others barriers put the procedure out of reach. The rise we observed was temporary, but suggests future threats to abortion access may induce the same shifts.
This change reflects a troubling new reality: decisions about reproduction may be increasingly shaped not by choice, but by the specter of abortion bans. A positive pregnancy test was already life-altering. Post-Dobbs, it carries even more weight. Even in states where abortion remains legal, like Pennsylvania, the threat of losing access exerts an effect on patients’ reproductive decisions.
The burden of contraception has always fallen disproportionately on women, and tubal sterilizations remain more common in Black and Hispanic females and in those with lower income, less education, and who have had more children.
In this post-Dobbs reality, physicians must listen carefully to patients requesting sterilization and ensure they are supported in making informed, voluntary decisions. Sterilization is never a substitute for abortion access. Abortion is safe, essential health care. But growing evidence shows erosion of abortion access reverberates across every corner of reproductive medicine.
That is why all of us have a role to play. Patients must feel empowered to obtain the contraception that best meets their needs, without delay or stigma. Physicians must confront and remove unnecessary barriers, even when requests challenge our assumptions. And policymakers must both safeguard abortion access while dismantling outdated regulations like the 30-day waiting period only Medicaid recipients are subject to, that undermine reproductive autonomy.
Our collective responsibility is to ensure that choice, even in the face of the looming threat of abortion bans, guides every decision about whether and when to become a parent.
Alice Abernathy MD is a Senior Fellow of the Leonard Davis Institute of Health Economics and an Assistant Professor in the Department of Obstetrics and Gynecology at the Perelman School of Medicine at the University of Pennsylvania.
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